Presentation “Harnessing EHRs and Health IT to Achieve Population Health” Jonathan Weiner, DrPH Professor Department of Health Policy and Management Director of Center for Population Health IT Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland Professor Weiner’s presentation will focus on how electronic health records and other e-health tools can be harnessed to move beyond providing medical care for a single patient episode towards the achievement of “population health.” This provocative presentation will offer new conceptual paradigms and will review “big data” opportunities and challenges. The emphasis of the talk will be on how population focused care transformation can be brought about through the integration and application of e-health/EHR systems and claims/MIS systems. The talk will offer examples of analytic tools and methods designed to increase the effectiveness, efficiency and equity of care provided at a geographic community level and to “populations” of consumers enrolled in health plans, ACOs and other integrated delivery systems. Key goals of presentation: ∙ To offer frameworks and paradigms to better understand how EHRs and other HIT can improve population health ∙ To outline opportunities and challenges for communities, ACOs and other integrated delivery systems ∙ To offer some case studies on the application of health IT to population health

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Harnessing Electronic Health Records
and Health Information Technology to
Achieve Population Health
Jonathan P. Weiner, DrPH
Professor of Health Policy & Management and of Health Informatics,
Director of the Center for Population Health IT (CPHIT)
The Johns Hopkins University, Baltimore Maryland, USA
Jweiner@jhsph.edu, www.jhsph.edu/cphit
Presented at the Institute for Health Technology Transformation
(IHT2) – NYC, NY. September 18, 2013

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The digitalization of medical care delivery
is at a tipping point
Source: USDHHS, CDC-National Center for Health Statistics - 2013

3. THE OPPORTUNITIES FOR IMPROVING THE
HEALTH OF POPULATIONS WILL BE PROFOUND:
• Using EHRs linked to smart phones, a medical director could
identify, monitor and improve the care of tens of thousands of
persons with chronic diseases living in her community.
• A scientist could evaluate the community health impacts (and
cost) of a new medical intervention in near real time.
• Social services, environmental health and medical care data
could be fully integrated in real time to maximize health for
targeted special populations in a geographic catchment area.
• Consumers, doctors, public health officers and nurse outreach
workers could all share real time information and clinical
guidance in the event of a disease outbreak.
• Based on public health analyses, an entire health delivery
system could modify its standards of care within a few weeks of
a major new scientific discovery.
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4. 4
In this presentation I will discuss:
• Trends and frameworks related to electronic
health records (EHRs), “e-health” and health IT
(HIT) of special relevance to populations,
communities and other target “denominators.”
• The potential for HIT to improve the:
 health of populations and
 the effectiveness and efficiency of integrated health
care delivery systems.

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Medical Care / Clinical
Sciences
Health
Informatics /
HIT
Population /
Public Health
Sciences1
Population Health IT: Disciplines and Examples
Population HIT Examples:
1. Assessing community
health status & need
2. Public health surveillance
3. Improving performance
for populations served by
integrated delivery system
4. Population decision
support for prevention /
chronic care management
5. Consumer e-health in
support of wellness/ care
management
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A few working definitions:
Healthcare Information Technology (HIT) - The application of
electronic health records (EHRs) and other digital technologies to the
delivery and management of health care. “Interoperable” EHRs
represent the backbone of a national healthcare information
infrastructure.
Health Informatics - The systematic application of information and
computer sciences and technology to health care practice, research,
and learning.
E-health - Health and health care practices supported by electronic
processes and communication. The term is inconsistently used: some
use it interchangeably with HIT. Others use it more narrowly as
consumer targeted health and health care support delivered or
enhanced through the internet or mobile (“m-health”) devices.

7. Healthcare Analytics - the leveraging of electronically
available healthcare data to enable actions that improve
health system effectiveness, efficiency or equity.
Population Health- A comprehensive framework for
assessing and improving the health and well being of a
defined population. Population health is practiced by private
and public organizations that focus on communities, persons
“enrolled” by a health care organization, or other groupings of
individuals that comprise a specific cohort of interest.
Public Health - Societal (i.e., government) actions to improve
health. The core public health functions relate to assessment,
assurance and policy setting.
7
Working definitions – Cont.

8. CDC’s estimates of impact of each determinant on mortality and morbidity.
Social Determinants, Environment and Behaviors
are Key to Achieving “Population Health”
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9. The e-health / HIT framework that will soon define
the “digital health care milieu”
Physician Patient
Practice Family
Team
EHRs Web-Portals
M-health
Apps
PHRs
e-mail / internet/
Social networks
Secure
Messaging
ICT / wireless
& wired
Biometric/
Telemed
CDS /
POE
ACO= Accountable Care Organization
EHR = electronic health record
PHR = personal health record
CDS = clinical decision support IT
systems
MIS/HIS = Management/Health IT
systems
POE = provider order entry IT systems
Claims/
MIS/
HIS
PH/ HR
IT
PH/HR = public health / human resource IT
systems
Telemed = telemedicine/ remote patient
monitoring-M-health = mobile health
applications
ICT = information / communication technology
Source: Weiner, 2012 http://www.ijhpr.org/content/1/1/33

10. Applying HIT to achieve care
that is:
- Population focused
- High value, and
- Integrated

11. HIT and population health is core to the
Patient Centered Medical Home (PCMH)
Integrate
E-prescribing
And
COES
EHR/HIE
Connected
Public Health
Bio Surveillance
Connected
Two way Quality
Reporting
Electronic
Eligibility
System
Interface
Electronic
Patient Access
and
Communication
E-Clinical
Decision
Support
Patient
Registry
Databases
Advance
Chronic
Disease
Mgmt
Medical Home
2.0
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Source: US Medicare
(CMS) Innovation Center

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Source: Premier Healthcare Alliance
HIT is core to the Accountable Care
Organization (ACO)

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Transforming Health Care Will Require
Paradigm Shifts and HIT Support
TRANSFORMEDCURRENT
Coordinated /Integrated CareFragmented Care
Patient / Population FocusedProvider Centric
Payment for Value / OutcomePayment for Volume / Units
Care System FocusedIndividual Facility Focused
Care Team AccountabilityPhysician Accountability
TransparencyOpaque rules and systems
Wellness / Chronic co-morbiditiesDisease oriented / Acute Illness
Evidence-Based Care /Learning Organiz.Limited Basis for Clinical Action
See: Weiner –Executive Insight Magazine Nov 2011,:
http://healthcare-executive-insight.advanceweb.com/Archives/Article-Archives/Virtual-Glue-for-a-Transformed-Healthcare-System.aspx

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Key applications of HIT for “population health
decision support” within integrated delivery
systems
• Risk identification / stratification for
targeting priority populations/patients
• Provider focused process improvement
focusing on patient “denominators”
• Patient / consumer targeted care
management and wellness using “e-
health” / “m-health” tools
• High level monitoring of outcomes/value
of the entire target population

15. Population Health Informatics at Johns
Hopkins (JHHC)
Inputs
Outputs
Case Manager Medical Directors
Clinical
Management Team
Patient Care
Reports
Provider Profile
ACG Risk
Measures:
Scientific
Knowledge:
clinical guidelines
Clinical / EHR/
Lab Results
Claims, Rx,
Enrollment,
Self-reported
Health Risk Data
Population Statistics
Population Groups
Users
Informatics
Update
Monthly
Review
Annually
Update
Monthly
Update
Monthly
Claims/Operations
Tables
Lab Results
Tables
ACG
Tables
Scientific
Tables
Update monitored patient and clinical events tables
Monitored Patient
Tables
Clinical Events
Tables
Create Reports Routinely and on Demand
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16. Using Predictive Models to Identify Patients at Risk for
Future Hospitalization:
Our Johns Hopkins ACG “PM” system is used in 18 nations
1.6%
1.2%
3.0%
94% 6%
Distribution of JHU ACG
"Probability of
Hospitalization" PM Risk
Score
.3 to <= 1.0
.2 to < .3
.1 to < .2
.0 to < .1
0%
20%
40%
60%
80%
100%
.0to<.1
.1to<.2
.2to<.3
.3to<.4
.4to<.5
.5to<.6
.6to<.7
.7to<.8
.8to<.9
.9to…
2%
28%
47%
59%
78%
100%
Percent Actually Hospitalized by
ACG Predictive Model Risk Score
Scores Based on ACG Version 9.0 Hospitalization Prediction Risk Model - This is for a
Medicaid Cohort enrolled in private health plans. (See: www.acg.jhsph.edu)

17. •
Source: CMS Innovation Planning Grant Received by the Maryland DHMH
Hot-Spotting Baltimore Hospitalizations Using HIE Data

18. Johns Hopkins CMS Innovation Grant – Community Health Partnership
Grant Targeting Population in East Baltimore
Characteristics of high-risk group:
• 36% have 6+ chronic conditions.
• 47% have 1 or more hospital admissions
during Nov 2011- Oct 2012
• 1,117 total admissions (76% all
admissions)
• Total cost of care is $30 Million
• Average of $29,679 per person per year
Characteristics low/ moderate risk Group:
• 6% have one admission
• Total cost of care is $29 Million
• Average of $5,463 per person per year
High
Complexity
1000 people at
six clinics
Moderate and Low
Complexity
5,258 people at six clinics
JHU ACG
Risk Score
Using JH
EMR/HIT
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19. Pop HIT Challenges: We need
• To find ways to integrate disparate “numerators” &
“denominators” to define true populations and
communities.
• Models and tools to help medical care systems
move towards population perspectives.
• Computer science / informatics technical tools that
facilitate public health and population health
operational needs. To date main focus has been
on clinical and administrative issues.
• Advanced tools for extracting and analyzing
unstructured data.
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20. Population Health IT Challenges - 2
• Standards and frameworks for integrating across
EHR / IT vendors to achieve true community
standards in this domain.
• New policy/legal frameworks and financial
structures that support population focus.
• Closer collaboration between government,
providers, payers/regulators, IT industry and
academia.
• Viable models for supporting ongoing
development and dissemination of evidence and
tools in the population health IT area.
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21. The Johns Hopkins Center for Population
Health IT (CPHIT) -- Mission and Focus
The mission of CPHIT (“see-fit”) is to improve the health
and well-being of populations by advancing the state-of-
the-art of Health Information Technology (HIT) and e-
health tools used by private health care organizations and
public health agencies.
CPHIT’s focus will be on the application of electronic health
records (EHRs), e-health and other digitally-supported
health improvement interventions targeted at
communities, special need populations and groups of
consumers cared for by integrated delivery systems
(IDSs).
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22. 1. Development and testing of health status and quality
measures created from EHRs and other HIT systems.
2. Use and advancement of computing methodologies –
including natural language processing (NLP) and pattern
recognition tools.
3. Initiation of effective approaches for linking provider-
centric EHR systems with consumer-centric internet and
mobile-based e-health applications.
4. Development of EHR-based tools and decision support
applications to help manage high risk populations.
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Some Key priorities of JHU CPHIT
R&D Center

23. Scope of CPHIT’s Activities
• Establish a leadership role in the development of a
national/global research agenda for population HIT.
• Undertake breakthrough and translational R&D and
associated technology transfer.
• Establish a comprehensive R&D infrastructure with
access to EHR data and a large cadre of multi-
disciplinary Johns Hopkins University (JHU) faculty.
• “Industry Partners” program to initiate and maintain
active collaboration with industry stakeholders.
• Further the education of the next generation of
population health informatics specialists.
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Challenges, Opportunities Future
Directions

25. Further Information
Center Director
Prof. Jonathan Weiner, DrPH
jweiner@jhsph.edu, 410 955-5661
The Johns Hopkins Center for Population Health
Information Technology (CPHIT)
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www.jhsph.edu/cphit